Failure to Notify Resident Representative of Injuries
Penalty
Summary
The facility failed to notify the resident's representative (RR) in a timely manner regarding two separate injuries sustained by a resident with diagnoses including heart failure, dementia with behavioral disturbance, and anxiety. The resident was dependent on two staff members for activities of daily living and had severely impaired cognition. The first injury involved bleeding from the resident's toe, and the second was a skin tear to the left wrist that required steri-strips and a dressing. In both cases, there was no documentation that the RR was notified of the injuries, despite facility policy requiring timely family notification and documentation of such contact in the incident report and nursing progress notes. Interviews with nursing staff and the Director of Nursing revealed that while the provider and internal facility leadership were notified, there was no evidence that the RR was informed of either injury. Staff members could not recall notifying the family, and documentation to verify notification was not found. The administrator confirmed the lack of documentation and stated that one injury had been brought to the facility's attention by the RR, not by staff notification. This failure to notify the RR as required by policy and regulation was confirmed through record review and staff interviews.